Elsevier

American Heart Journal

Volume 198, April 2018, Pages 180-188
American Heart Journal

Clinical Investigation
Factors of health in the protection against death and cardiovascular disease among adults with subclinical atherosclerosis

https://doi.org/10.1016/j.ahj.2017.10.026Get rights and content

Background

Although cardiovascular disease (CVD) prevention traditionally emphasizes risk factor control, recent evidence also supports the promotion of “health factors” associated with cardiovascular wellness. However, whether such health factors exist among adults with advanced subclinical atherosclerosis is unknown. We aimed to study the association between health factors and events among persons with elevated coronary artery calcium (CAC).

Methods

Self-reported health-factors studied included nonsmoking, physical activity, Mediterranean-style diet, sleep quality, emotional support, low stress burden, and absence of depression. Measured health-factors included optimal weight, blood pressure, lipids, and glucose. Multivariable-adjusted Cox models examined the association between health factors and incident CVD or mortality, independent of risk factor treatment. Accelerated failure time models assessed whether health factors were associated with relative time delays in disease onset.

Results

Among 1,601 Multi-Ethnic Study of Atherosclerosis participants with CAC > 100 without baseline clinical atherosclerotic CVD, mean age was 69 (±9) years, 64% were male, and median CAC score was 332 Agatston units. Over 12 years of follow-up, nonsmoking, high-density lipoprotein cholesterol levels >40 mg/dL for men and >50 mg/dL for women, and low stress burden were inversely associated with ASCVD (hazard ratios ranging from 0.58 to 0.71, all P < .05). Nonsmoking, glucose levels <100 mg/dL, regular physical activity, and low stress burden were inversely associated with mortality (hazard ratios ranging from 0.40 to 0.77, all P < .05). Each of these factors was also associated with delays in onset of clinical disease, as was absence of depression.

Conclusions

Adults with elevated CAC appear to have healthy lifestyle options to lower risk and delay onset of CVD, over and above standard preventive therapies.

Section snippets

Study participants

MESA is a community-based cohort study of the prevalence, correlates, and progression of subclinical and clinical ASCVD. Details of the MESA study design and objectives are reported elsewhere.14 Briefly, 6,814 participants between the ages of 45 and 84 free of clinical ASCVD at baseline were enrolled between 2000 and 2002 (visit 1) at 6 US field centers (Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles, CA; New York, NY; and St Paul, MN). Four follow-up visits were conducted in 2002

Study cohort

The study population consisted of 1,601 MESA participants. The mean (±SD) age was 69 (±9) years, 64% were males, 49% were white, 22% African American, 18% Hispanic, and 10% Chinese. The median (IQR: 25th-75th percentile) baseline CAC was 332 (177-677) Agatston units. Baseline characteristics, overall and according to presence of incident hard ASCVD events during follow-up, are summarized in Table I. Compared with individuals who developed incident ASCVD events, those who remained free of ASCVD

Discussion

The current study demonstrates modifiable health factors that are associated with lower risk and delay in onset of ASCVD or death among individuals with subclinical atherosclerosis as determined by elevated CAC. Specifically, nonsmoking, adequate physical activity, absence of chronic stress, high HDL-C levels, and normoglycemia were inversely associated with risk of hard ASCVD events and/or death. There were also favorable trends for Mediterranean diet, emotional support, and absence of

Summary statement

The presence of high CAC does not predetermine the development of clinical CVD, and this analysis demonstrates that adults with subclinical atherosclerosis have behavioral and psychosocial options to improve their prognosis over and above standard preventive therapies such as aspirin and statins.

Conflict of interest statement

The authors report no conflicts of interest relevant to this work.

Acknowledgements

This research was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168, and N01-HC-95169 from the National Heart, Lung, and Blood Institute and grants UL1-TR-000040 and UL1-TR-001079 from the National Center for Research Resources. The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. A full list

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